Cancer Pain Management

Welcome to Cancer News Line, a weekly podcast
series from the University of Texas, M.D.AndersonCancerCenter in Houston. I'm your host Dr. Edward Kim,
Associate Professor in the Department of Thoracic, Head and Neck Medical
Oncology. Cancer News Line is a source of cancer news that helps you stay
current on the latest information on treatment, research, prevention and
survivorship. Today, we are talking about one of the most common and complex
side effects experienced by patients diagnosed with cancer, pain. About one
third of patients being treated for cancer experience pain and it can take many
forms. Whether chronic or acute, pain is unique to each patient and it is vital
that each patient's pain treatment plan be tailored to their personal needs.

Joining me today is Dr. Allen Burton, Professor and Chair of M.D.
Anderson's Department of Pain Medicine. Dr. Burton and his team provide a
multidisciplinary approach to treating pain and related symptoms, all with the
ultimate goal of giving patients and survivors an improved quality of life.
Under Dr. Burton's leadership, the Department of Pain Management recently was
recognized by the American Pain Society as one of the nation's five clinical
centers of excellence and it was the first cancer pain clinic to receive the
award. Dr. Burton also is the current president of the Texas Pain Society.
Thank you for speaking with Cancer News Line today, Dr. Burton.

Dr. Allen Burton:

It's a pleasure to be here.

Dr. Edward Kim:

So let's first start by defining what really is cancer
pain. What is the cause of it, how do you measure it?

Dr. Allen Burton:

Cancer pain is one of the most feared symptoms of cancer and most
famously, cancer pain comes from the tumor itself. Tumors themselves can
actually cause discomfort when they're rapidly growing but mainly tumors cause
pain by their location in the body. Tumors that are growing into bone or into
an organ or into the nervous system can be extremely painful whereas a slow
growing tumor that maybe in the abdomen may cause very little symptoms until it
is quite advanced. So, this is the most common source of cancer pain that often
gets worse when the cancer becomes further advanced or untreatable. A related,
more common issue that we're seeing today is the pain that comes along with
cancer treatments or indeed the pain that is seen in cancer survivors. This
becomes more of a chronic pain situation and to some extent, we are victims of
our success and disregard as the oncologic treatments
have gotten more sophisticated and increasing in their success, some of the
fallout is chronic pain in some of the cancer survivors.

Kim:

I imagine it becomes more complex as patients go through longer and
longer periods of treatment. Being a lung cancer doc, we're trying to get there
but of course in breast cancer we see this quite often where patients are being
treated for many years and even decades and probably have this type of problem
occurring.

Burton:

Certainly, we have some recent data that shows about a third of cancer
survivors complain of some ongoing chronic pain issues and perhaps as many as
the third of those have very severe pain that is an ongoing problem for them
for which they need ongoing medical care, sometimes for years or decades to
come. And as you correctly stated some of the more survivable cancers, i.e. the
early stage breast cancer, many of those patients, in some studies up to 50
percent of post-mastectomy patients have some ongoing discomfort.

Kim:

Now what types of treatments or other aspects do you approach when you
see patients in your clinic and what types of prescribed therapies are you offering patients?

Burton:

Some of the most common treatments that we utilize for pain, again, it's context specific. So patients that are in active
treatment for their cancer that have ongoing needs for chemotherapy, radiation,
they have upcoming or recent surgeries, these patients
have a goal of getting through their treatment successfully. So our goal is to
just really make that pain tolerable. Keep the patients active and treat
concomitant symptoms like nausea, or fatigue, or insomnia, and keep the
patients' energy level up and keep them functional in order that they may
successfully complete their cancer treatment. When the context shifts and the
patient becomes a survivor or they become a long-term remission or with a very
indolent, slowly progressive cancer, then some of our goals take on a more
complicated longer-term nature where we begin to shift into some chronic pain
treatment algorithms.

Kim:

I can imagine it's so subjective when someone complains of different
symptoms or pain and it's very easy when there is a lesion you can see or if
they've had a surgical procedure done. How do you assess in clinic with some of
these patients?

Burton:

Well, as you very correctly point out pain is a subjective symptom. It is
sometimes very difficult to see and for this reason, pain has often been under
recognized and under treated because the patients, it's not obvious when a
patient's having pain. We do have a variety of assessment tools. The most
common one is just simply asking the patient and an awareness that there are
chronic pain treatment sequel that can come after surgery, after chemotherapy,
after radiation, or indeed just from having a tumor located in a sensitive spot
and now when the tumor is ablated, the nerves in that spot for example don't
grow back properly or they grow back into a bundle of nerves called a neuroma or another painful condition.

And many times in the past, the ongoing survivorship was limited so we
didn't really have an opportunity to fully study and evaluate these and really
recognize these as clinical problems. Now with the increasing, I guess with the
combination of early diagnosis, better cancer therapies, we really are much
more able to quantify these syndromes and we're getting, I think, a lot better
at treating them quite successfully and improving the long-term quality of
life. As the problems become more complex medically with the patient, the
treatment algorithms become more complex involving a psychologist, often a
physical or occupational therapist, sometimes a physical medicine physician to
help guide that rehabilitative therapy and then a pain specialist to provide
the analgesic component whether that's medications, topically other
interventional procedures or sometimes even holistic measures.

Kim:

Now you just segueing on what you just mentioned here. I think many of
us, especially your colleagues here at M.D. Anderson, view pain management
mostly through pharmaceutical means and you alluded to several other techniques
and other aspects of it. Could you fully go into more full description on other
techniques that are available?

Burton:

Certainly, I think that, again, in keeping with one of the themes is
personalized medicine and we really try to address the patient's pain in
context and when the patient is facing an acute cancer situation where they
have a tumor that's there, that they're going through active treatment on, then
often the most appropriate course of therapy is pharmacologic and these often
takes the form of episodes and/or adjuvant medications. Some of the more
commonly used opioid medications are hydrocodone or morphine and some of the more commonly used
adjuvant are gabapentin or Neurontin
or pregabalin which are anti-neuropathic
or anti-nerve pain medicines and sometimes these are blended in order to just
bring the pain down to a tolerable level so the patient can continue on in
their therapy. When the patient shifts into a more chronic pain mode,
oftentimes the psychological issues begin to intertwine to a great degree and
this is somewhat inevitable with chronic pain. The patient begins to ruminate
on the pain.

The pain impact on their ability to get back into fully into their life
and for instance, go back to their vocation or go back to their full roles as a
family member, as a productive member of society, and there's a great deal of
uncertainty even am I fully cured, is the cancer fully behind me, will it come
back, you know how am I going to deal with this, is sort of a related set of
issues and then when you impact that with a day-to-day high level of symptoms in
the form of pain, that pain can be a constant reminder of that sort of lurking
threat of recurrent cancer or gee, I'm not sure the caner is really in
remission, why do I hurt so much if I'm cured of cancer. And so, these patients
have a complex psychological set of issues that really needs teasing apart and
guidance on how to compartmentalize those, how to set goals and how to slowly
get back to their previous productive self.

Kim:

Well, in that same vein, we mention a word like addiction, and addiction
is used in such a negative context or at least perceived in that way although
there are many addicts who are addicts to good things as well. How do you deal
with someone with addiction and alluding to the fact that again, when the pain
goes away, it may seem like they associate that with the cancer going away as
well?

Burton:

Addiction is always a very common issue when you start talking about pain
medications, just because of the fact that many of the medications that are
used to treat pain also can have addictive properties to them and there have
been some famous cases of celebrities that have had addictions to pain
medications. Over the past 10 to 15 years, there's been an increasing push on
the need to treat pain. With this has a come a surge in the prescribing of opioid medications particularly to patients. And along with
that, has become an increasing misuse of these medications out in either in
non-patients or patients misusing their medications. Some patients have
preexisting, before their cancer, before their pain, have preexisting problems
with addictions either chemically coping with situations through the use of
illegal drugs, prescription drugs or alcohol, and sometimes those life patterns
or those psychological traits that led them into an addiction will come back
with the stress of a cancer or the stress of an ongoing chronic pain issue. So
the pain community is increasingly aware that the medications we use have the
potential to cause addiction. But some patients do require the ongoing use of
medications with an addictive potential. That doesn't mean that those patients
are addicted to those medications in the same way that a diabetic, for example,
is not addicted to insulin. Or that a hypertensive patient is not addicted antihypertensives. We are increasingly aware of a subset of
patients that may get into trouble with pain medication such as accelerating
the use, using inappropriate doses, using them not as prescribed, and we are
aware that there are a subset of patients that may get
into trouble with these medications. The vast majority of patients will not
have those issues.

Kim:

And many of my patients will ask about acupuncture and other sort of
non-pharmacologic means. How common are these being used these days?

Burton:

I think there's a growing awareness of the importance of alternative,
more holistic therapies to the extent that there is a department here at M.D.
Anderson that is devoted to studying and utilizing these techniques. We are
close collaborators. We refer many patients through our center for acupuncture
and related techniques. Our psychologist applies cognitive behavioral therapies
and biofeedback in our center and we do believe that there is a role for these
techniques. The mind is, if you will, is the central processing unit of all
pain signals and there's many ways that the mind can impact or filter the
signals differently. And some of those are well understood and some are only
now beginning to be opened up and teased apart. So we think it's best to use a blend
of standard techniques like medications and perhaps nerve blocks where
appropriate as well as some of these holistic techniques. Again, some of it is
patient driven. Certain patients really seek this and some of it patients that
are just not doing well with conventional therapies. So, I think all of those
patients are appropriate. And finally, I think it's important that we're
studying these techniques in trying to bring that level of evidence for using
some of those techniques up. One of our colleagues is currently doing finishing
up an acupuncture study that has been quite exciting.

Kim:

Well, I imagine this is an extremely underreported aspect of medicine in
general and especially in cancer care. What suggestions would you have to our
listeners out there right now who either are being treated right now or have a
loved one who's being treated? How do they approach their doctor about being
referred to a pain specialist and when in the equation should a pain specialist
be brought in to help with the patients?

Burton:

I think that's a very good question and I would encourage the listener,
even in the often, the listener is under time pressure. Their oncologists are
very busy. They have just a few minutes periodically with the oncologist. They
have really important questions to ask them, is the tumor smaller, am I going
to need more therapy, indeed these are sometimes life and death issues. So the
patient tends to hit the oncologist with the kind of hard questions and then
often they'd get through the visit or they're on their way out the door going
home and they really haven't mentioned some of the symptoms that they're
dealing with and living with on a day-to-day basis.

So there are a couple strategies. We encourage our patients to write down
things before they come to the oncologist office. Obviously, their most
important questions are going to have to do with their chemotherapy, their
cancer, ect., but we encourage them to write down symptoms that they're
having. Are they having a lot of nausea? Are they having appetite problems? Are
they having pain? What kind of pain? Is it located with the tumor? Is it from
where they had surgery 6 months ago?

What is the pain easy to treat with just a Tylenol, or is it something
that is really bothering them, keeping them up at night, keeping them from
functioning. If it's at the point where it's really impacting their life
significantly, and that's different for a given patient. It may interrupt
sleep, it may interrupt the ability to walk, it may
interrupt the ability to function to any extent other than just perseverating
on the pain. If the pain is that severe, they certainly should talk, if not to
the oncologist, then to the nurse practitioner or to the oncologist nurse or
team about that. And even perhaps bring it up with the oncologist who at that
point may often make an attempt. And oncologists are very good symptom managers
and will be able, in most cases, to provide some prompt addressing of that
symptom. And often, I would say, at least 50 percent of the time, the
oncologist with a medication or two or prescribing physical therapy will be
able to address those symptoms successfully. When their first or second line
treatment for that symptom is not working out then generally, the oncologist in
discussion with the patient or they'll decide, or you know, some collaborative
decision making will be, "I think we're beyond our level of expertise
here. Let's get somebody else involved." And in our setting, that would
probably be the pain medicine department.

We also have palliative care colleagues, that supportive care that are
very good at this in context, you know, again, depending on the patient's
situation. And in the community, there may be different avenues for this. There
may be general practitioners who do pain medicine. There may be hospital
practitioners who do this or there may be pain specialists and some of it may
be local variations, but generally, the goal would be to get to another level
of care where multidisciplinary care can be applied.

Kim:

So, Dr. Burton, could you describe some new areas of pain research that
you find are most promising and perhaps things that we may be able to integrate
into our patient care over the next several years?

Burton:

Dr. Kim, we have a variety of areas of research that are actively ongoing
in the pain community and also here at M.D. Anderson. Some are to do with
injection therapies that would be toward the end of life that would help ablate
nerve pathways that are causing significant pain and discomfort. Some are
evaluating new technologies such as new pain pumps that are more interactive
with the patient and providing analgesia or pain relief when the patient needs
it but not on an ongoing basis. More tailored to controlling their symptoms.
And finally, in the area of pharmacologic, there are several new medications
that are in phase 2 and phase 3 trials for treating severe cancer pain, and
also different types of cancer pain, such as that following shingles or
following the pain of surgery, and a variety of these new medications are again
in the clinical trial phase but they are showing some promise. And then lastly,
our integrative medicine colleagues have a variety of symptom-related research
ongoing. Again, some of it in collaboration with us in chronic cancer pain
situations. So there's a really a--it is a burgeoning area of research that is
quite exciting.

Kim:

Well, I can speak from my own experience that your department and what
you're doing has really been helpful to our patients and in our overall
multidisciplinary care here at M.D. Anderson. Allen, thank you! For joining
Cancer News Line today and reminding us all that there is hope for those
suffering from cancer pain.

Burton:

Thank you, Dr. Kim.

Kim:

Thank you for tuning in to Cancer News Line this week, and be sure to
check out another new edition next week..